According to the authors of Governance as Leadership: Reforming the Work of Nonprofit Boards, generative governance is where real leadership power lies. It's where the board has a clear sense of problems and opportunities facing the organization. Meaningful goal setting and direction setting originates from generative thinking, which requires leaders that not only contribute generative insights to their hospitals, but also engage others in generative thinking. It occurs when boards question assumptions, probe feasibility, identify obstacles and opportunities and determine alternate ways of framing issues.

Generative governance requires a new type of agenda that features ambiguous or problematic situations rather than reports and routine motions, with a goal to frame decisions and choices, not simply make them. Trustees promote robust dialogue around generative ideas and concepts, which stimulates a "culture of inquiry," creating more substantive and intellectually attractive agendas that create more interesting and productive work, and a more influential role for board members.